The Centers for Medicare and Medicaid Services (CMS) should begin monitoring access to—and quality of—dialysis care as soon as possible after implementation of the new payment system, particularly for groups of beneficiaries with above-average costs of care, concludes a recently released report from the Government Accountability Office (GAO). GAO also suggests that CMS could use the information to help refine the system over time.
Commissioned in response to questions raised about the impact of the new bundled payment system for end stage renal disease (ESRD) care—effective on January 1, 2011—the report draws on USRDS data as well as interviews with clinicians and researchers with expertise in ESRD. In the course of its research, GAO sought input from ASN. The Society facilitated a discussion among GAO researchers and ASN members Jonathan Himmelfarb, MD, FASN; Glenn Chertow, MD; Jula Inrig, MD; Suzanne Watnick, MD; and Jeffrey Berns, MD.
Some beneficiary groups have above-average drug expenditures
Certain groups of dialysis patients have above-average Medicare expenditures for injectable ESRD drugs, the report found. African Americans in particular had higher than the average costs across all beneficiaries on dialysis in 2007. Medicare spending for patients with additional coverage through Medicaid was also higher than the average across all beneficiaries on dialysis.
Besides studying expenditures by demographic characteristics, GAO also collected information from nephrology clinicians and ESRD researchers on the factors they consider likely to result in above average doses of injectable drugs—ESAs, iron, and vitamin D. A majority of the nephrology experts interviewed by GAO identified primarily clinical factors, rather than demographic, as driving variation in these expenditures. Chronic blood loss, low iron stores, and recent hospitalization were among factors identified as likely to result in above average doses of ESAs.
CMS’s preliminary monitoring plans build on existing initiatives…
GAO also examined CMS’s plans for monitoring the effects of the new bundled payment system on beneficiaries.
CMS officials interviewed by GAO indicated that initial plans for monitoring build on three existing initiatives: the ESRD networks, the Clinical Performance Measures, and a survey and certification program (Table 1). In addition to these initiatives, the report notes that CMS has or is developing two other initiatives focused primarily on promoting the quality of dialysis care rather than monitoring—the Dialysis Facility Compare tool and a quality incentive program (QIP), with an implementation date of January 1, 2012.
…But extent to which CMS will monitor care for specific beneficiary groups is uncertain
Because CMS is still developing its monitoring plans, it is uncertain to what extent CMS will monitor the quality of dialysis care for specific groups of beneficiaries—such as those with above-average costs of care—under the new bundled payment system, according to the GAO report. The report emphasizes that the three existing CMS initiatives involve systematic monitoring of just one measure of access to care (the extent to which beneficiaries are involuntarily discharged from dialysis facilities).
GAO identifies possible opportunities to monitor patient access
Data needed to conduct more comprehensive monitoring of access for various groups of beneficiaries are available to CMS, GAO reports. Specifically, CMS could use the Dialysis Facility Report (compiled by the University of Michigan-Kidney Epidemiology and Cost Center) to compare characteristics of patients in facilities that open or close during a given year, indicating whether openings or closures affect availability of dialysis care for certain groups of patients more than others.
CMS also has the data needed to monitor changes in the use of dialysis services and shifts in sites of care, according to GAO. CMS could use data it collects in the process of paying claims for Medicare-covered services—such as ESRD drugs—as well as the CrownWeb database to monitor the use of dialysis services for groups of beneficiaries with above-average costs of care. Changes in the use of dialysis services could indicate how the new bundled payment system may be affecting patient access to services, GAO noted. With this data, CMS might, for instance, compare dialysis-related drug use between groups of beneficiaries and assess whether any usage discrepancies were appropriate, GAO said. CMS could also monitor the extent to which beneficiaries receive emergency dialysis in hospitals rather than outpatient dialysis facilities. An increase in emergency dialysis services for certain groups could indicate that these groups face difficulty obtaining care in outpatient units.
Responding to the GAO’s report, CMS reiterated that it plans to have a “comprehensive monitoring system” that examines care of all ESRD beneficiaries—including those with above-average costs—in place when bundled payments go into effect.
“With the implementation of any new payment system, CMS places its foremost concern on the impact of the change on beneficiary access and quality of care,” said Center of Medicare Deputy Administrator and Director Jonathan Blum.
Blum also noted that GAO based its findings on interviews conducted with CMS staff before the Proposed Rule for the new ESRD Bundling was issued. However, GAO reports that it reviewed its findings with CMS staff after the release of the Proposed Rule in December 2009, and agency officials stated the information was accurate.
GAO is an independent, nonpartisan agency that produces reports and collects information upon request from Congress; its recommendations are nonbinding.
Learn more about the GAO Report on ASN’s Patient Care Policy webpage (http://www.asn-online.org/policy_and_public_affairs/esrd-bundling.aspx), including:
GAO Report Highlights Page
Complete GAO Report
Letter on GAO Report to Rep. Pete Stark & Rep. John Lewis from Deputy Administrator and Director, Medicare, Jonathan Blum
